|
Lactated Ringers IV Sol 500 mL [HMC]
|
Facility
|
IP
|
$39.68
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
3256943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Lactic Acid
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS 83605
|
| Hospital Charge Code |
3553605
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$88.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Lactic Acid
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
HCPCS 83605
|
| Hospital Charge Code |
3553605
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$88.35 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$47.35
|
| Rate for Payer: Humana Medicare Advantage |
$39.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$88.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.08
|
| Rate for Payer: WPPA Medicare Advantage |
$55.80
|
|
|
lactobacillus acidophilus Cap [HMC]
|
Facility
|
OP
|
$5.09
|
|
|
Service Code
|
NDC 00761051520
|
| Hospital Charge Code |
3800828
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$4.58
|
| Rate for Payer: Humana Medicare Advantage |
$2.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.04
|
| Rate for Payer: WPPA Medicare Advantage |
$3.05
|
|
|
lactobacillus acidophilus Cap [HMC]
|
Facility
|
IP
|
$5.10
|
|
|
Service Code
|
NDC 00904421360
|
| Hospital Charge Code |
3800828
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.84
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lactobacillus acidophilus Cap [HMC]
|
Facility
|
IP
|
$5.09
|
|
|
Service Code
|
NDC 00761051520
|
| Hospital Charge Code |
3800828
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.84
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lactobacillus acidophilus Cap [HMC]
|
Facility
|
OP
|
$5.10
|
|
|
Service Code
|
NDC 00904421360
|
| Hospital Charge Code |
3800828
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$4.59
|
| Rate for Payer: Humana Medicare Advantage |
$2.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.04
|
| Rate for Payer: WPPA Medicare Advantage |
$3.06
|
|
|
lactulose 10 g/15 mL Oral Syrup 473 mL [HMC]
|
Facility
|
IP
|
$12.20
|
|
|
Service Code
|
NDC 00121087316
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.59
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lactulose 10 g/15 mL Oral Syrup 473 mL [HMC]
|
Facility
|
OP
|
$12.20
|
|
|
Service Code
|
NDC 00121087316
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.88 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$10.98
|
| Rate for Payer: Humana Medicare Advantage |
$5.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.88
|
| Rate for Payer: WPPA Medicare Advantage |
$7.32
|
|
|
lactulose 10 g/15 mL Oral Syrup [HMC]
|
Facility
|
IP
|
$12.65
|
|
|
Service Code
|
NDC 66689003950
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.38 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.02
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lactulose 10 g/15 mL Oral Syrup [HMC]
|
Facility
|
OP
|
$13.50
|
|
|
Service Code
|
NDC 00116400540
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$12.82 |
| Rate for Payer: Aetna Commercial |
$12.15
|
| Rate for Payer: Humana Medicare Advantage |
$5.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: WPPA Medicare Advantage |
$8.10
|
|
|
lactulose 10 g/15 mL Oral Syrup [HMC]
|
Facility
|
OP
|
$11.62
|
|
|
Service Code
|
NDC 00121457715
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$11.04 |
| Rate for Payer: Aetna Commercial |
$10.46
|
| Rate for Payer: Humana Medicare Advantage |
$4.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.65
|
| Rate for Payer: WPPA Medicare Advantage |
$6.97
|
|
|
lactulose 10 g/15 mL Oral Syrup [HMC]
|
Facility
|
IP
|
$15.02
|
|
|
Service Code
|
NDC 50383077917
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.52 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$13.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.27
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lactulose 10 g/15 mL Oral Syrup [HMC]
|
Facility
|
IP
|
$11.62
|
|
|
Service Code
|
NDC 00121457715
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.04
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lactulose 10 g/15 mL Oral Syrup [HMC]
|
Facility
|
IP
|
$14.37
|
|
|
Service Code
|
NDC 00121457740
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.93 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.65
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lactulose 10 g/15 mL Oral Syrup [HMC]
|
Facility
|
IP
|
$13.50
|
|
|
Service Code
|
NDC 00116400540
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.15 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.82
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lactulose 10 g/15 mL Oral Syrup [HMC]
|
Facility
|
OP
|
$12.65
|
|
|
Service Code
|
NDC 66689003950
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$12.02 |
| Rate for Payer: Aetna Commercial |
$11.38
|
| Rate for Payer: Humana Medicare Advantage |
$5.31
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.06
|
| Rate for Payer: WPPA Medicare Advantage |
$7.59
|
|
|
lactulose 10 g/15 mL Oral Syrup [HMC]
|
Facility
|
OP
|
$14.37
|
|
|
Service Code
|
NDC 00121457740
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.75 |
| Max. Negotiated Rate |
$13.65 |
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: Humana Medicare Advantage |
$6.04
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.75
|
| Rate for Payer: WPPA Medicare Advantage |
$8.62
|
|
|
lactulose 10 g/15 mL Oral Syrup [HMC]
|
Facility
|
OP
|
$15.02
|
|
|
Service Code
|
NDC 50383077917
|
| Hospital Charge Code |
3808736
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$14.27 |
| Rate for Payer: Aetna Commercial |
$13.52
|
| Rate for Payer: Humana Medicare Advantage |
$6.31
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.01
|
| Rate for Payer: WPPA Medicare Advantage |
$9.01
|
|
|
lamoTRIgine 100 mg Tab [HMC]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
NDC 00904700861
|
| Hospital Charge Code |
3800016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.22
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lamoTRIgine 100 mg Tab [HMC]
|
Facility
|
OP
|
$19.25
|
|
|
Service Code
|
NDC 65862022801
|
| Hospital Charge Code |
3800016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$18.29 |
| Rate for Payer: Aetna Commercial |
$17.32
|
| Rate for Payer: Humana Medicare Advantage |
$8.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.70
|
| Rate for Payer: WPPA Medicare Advantage |
$11.55
|
|
|
lamoTRIgine 100 mg Tab [HMC]
|
Facility
|
OP
|
$5.50
|
|
|
Service Code
|
NDC 00904700861
|
| Hospital Charge Code |
3800016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: Aetna Commercial |
$4.95
|
| Rate for Payer: Humana Medicare Advantage |
$2.31
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.20
|
| Rate for Payer: WPPA Medicare Advantage |
$3.30
|
|
|
lamoTRIgine 100 mg Tab [HMC]
|
Facility
|
IP
|
$19.25
|
|
|
Service Code
|
NDC 65862022801
|
| Hospital Charge Code |
3800016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.32 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$17.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.29
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lamoTRIgine 100 mg Tab [HMC]
|
Facility
|
OP
|
$5.69
|
|
|
Service Code
|
NDC 68084031901
|
| Hospital Charge Code |
3800016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$5.41 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: Humana Medicare Advantage |
$2.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.28
|
| Rate for Payer: WPPA Medicare Advantage |
$3.41
|
|
|
lamoTRIgine 100 mg Tab [HMC]
|
Facility
|
OP
|
$19.48
|
|
|
Service Code
|
NDC 29300011201
|
| Hospital Charge Code |
3800016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.79 |
| Max. Negotiated Rate |
$18.51 |
| Rate for Payer: Aetna Commercial |
$17.53
|
| Rate for Payer: Humana Medicare Advantage |
$8.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.79
|
| Rate for Payer: WPPA Medicare Advantage |
$11.69
|
|
